The new 2012 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

Heart Failure 2012

Topics:
Heart Failure (HF)

Date: 20 May 2012

Much has happened in heart failure since the last ESC Guidelines were published in 2008. As a result, each of the major sections of the guideline has been updated. In addition, the therapeutic recommendations more specifically relate the treatment to effects, with a focus on important clinical outcomes. For example, the evidence tables give beta-blockers a Class I, Level A recommendation as follows: “A beta-blocker is recommended, in addition to an ACE inhibitor (or ARB if ACE inhibitor not tolerated), for all patients with an EF ≤ 40% to reduce the risk of HF hospitalisation and the risk of premature death.” The 2012 guideline also includes new algorithms for diagnosis of the patient with suspected heart failure, treatment for heart failure with reduced ejection fraction (HF-REF) and the management of acute heart failure.

The diagnosis section of the guideline recognises the increasingly important role of cardiac magnetic resonance imaging in evaluation of patients with heart failure and includes mid-regional proANP as a “rule-out” blood test in patients with suspected acute heart failure. In the pharmacological therapy part of the 2012 guideline there is a new indication for the mineralocorticoid antagonist (MRA) eplerenone in patients with HF-REF and mild symptoms, broadening the indication for a MRA to essentially all HF-REF patients remaining symptomatic despite adequate treatment with a beta-blocker and ACE inhibitor (or ARB, if ACE inhibitor not tolerated). The addition of ivabradine to an ACE inhibitor, beta-blocker and MRA is also recommended in HF-REF patients in sinus rhythm with a persistently high heart rate despite optimised beta-blocker dosing.

In the non-surgical devices section, the wider use of cardiac resynchronisation therapy (CRT) in HF-REF patients with milder symptoms and in sinus rhythm is recommended. The new guideline does, however, acknowledge the uncertain role of CRT in patients in atrial fibrillation and in patients with non-left bundle branch QRS morphology. Transcatheter aortic valve replacement is recommended as a completely new treatment option in patients with severe aortic stenosis unsuitable for conventional surgical valve replacement.

Key new developments in surgery are new evidence on the role of coronary revascularisation from the STICH trial and the growing evidence that ventricular assist devices (VADs) have an important role in the management of patients with end-stage heart failure. The guideline addresses the use of VADs both as a bridge to transplantation and, in highly selected patients, as “destination therapy”.

The new guideline devotes substantial space to co-morbidities, given their importance in relation to symptoms and prognosis and therapeutic decision making. The guideline recognises that the presence of heart failure and left ventricular systolic dysfunction may alter therapeutic options for co-morbidities and that co-morbidities may also influence the use of heart failure therapies.

No substantive new evidence has emerged in the area of acute heart failure and this section of the guideline has been shortened and extensively revised with some regarding of recommendations in keeping with the guideline focus of improved clinical outcomes.

Non-pharmacological/ device/ surgical treatments other than exercise and multi-disciplinary intervention are not given a recommendation or evidence grading in the new guideline due to the emergence of uncertainty about the value of some (e.g. sodium restriction) and the lack of robust outcome data for others.

The Task Force felt that the role of remote monitoring remains to be clarified but recognised the role of palliative near the end of life in patients with heart failure.

Authors: John McMurray, FESC
University of Glasgow, Scotland
Chairperson of the ESC Guidelines on the diagnosis and treatment of acute and chronic heart failure 2012